Video Laryngoscopy

imagesRoutine intubation


imagesRescue for failed direct laryngoscopy


imagesAnticipated difficult intubation (abnormal anatomy, reduced mouth opening, history of difficult intubations, cervical spine precautions, obesity)


imagesIntubation with desire for teaching or supervision of physician trainees


RELATIVE CONTRAINDICATIONS



imagesBrisk bleeding or copious secretions


imagesNo oral access (angioedema)


imagesProvider discomfort or lack of training with indirect laryngoscopy and intubation


DEVICES



imagesMultiple devices are available


imagesDevices are broadly grouped into acutely curved blades (GlideScope, King Vision, C-MAC D-blade, Pentax airway scope) or traditionally shaped blades (C-MAC, GlideScope teaching blade)


imagesTraditionally shaped blades can be used as a direct and video laryngoscope to facilitate mechanical memory for direct laryngoscopy


imagesSome devices require free-hand placement of the endotracheal tube (ETT) (GlideScope, C-MAC, McGrath Series 5), while others have integrated ETT channels that require the device and ETT to be inserted together (King Vision, Pentax airway scope)


SUPPLIES



imagesVideo laryngoscope system


imagesETT


imagesETT stylet (malleable or rigid)


imagesETT lubricant


images10-cc syringe for cuffed ETTs


imagesEnd-tidal carbon dioxide detector


imagesTube securing device


imagesBag-valve mask


imagesOral and/or nasal airways


imagesEquipment for preoxygenation (facemask oxygen with reservoir)


TECHNIQUE—RAPID SEQUENCE INTUBATION



imagesPreparation


   imagesVascular access


   imagesMonitoring: Cardiac monitor, blood pressure monitoring, and pulse oximetry


   imagesSuction device


   imagesAssemble necessary equipment (see above)


   imagesObtain rapid sequence intubation (RSI) medications


   imagesPerform an airway assessment for difficulty


imagesPreoxygenation


   imagesPreoxygenate with nonrebreathing mask or bag-valve mask


   imagesNasal cannula for passive oxygenation during intubation, especially for rapid desaturators


imagesPositioning


   imagesCervical spine extension and head elevation if no contraindication


   imagesIn-line cervical spine neutrality for patients with cervical spine precautions


imagesPerform “Time Out”


   imagesEnsure that the team agrees on medications and dosing, devices to be used, and plan for a failed intubation


imagesAdminister Induction and Paralytic Agents


imagesPerform Intubation


Traditionally shaped video system blades (C-MAC, GlideScope teaching blade)


   imagesOpen mouth with a finger/scissor or similar technique


   imagesInsert the blade in the right paralingual gutter of the mouth, sweeping the tongue to the left


   imagesAdvance the blade in traditional technique with the goal of identifying epiglottis first (epiglottoscopy), followed by placement of the tip of the blade in the base of the vallecula


   imagesUsing an upward motion, lift up on the handle and blade to obtain a view of the vocal cords by manipulating the hyoepiglottic ligament


   imagesIf an optimal direct view is not seen under direct vision, the operator may attempt optimization maneuvers such as backward upward rightward pressure, or “BURP,” to improve view


   imagesAlternatively, the intubator can opt for early recourse to the video screen to assess glottic view and intubate using the video screen


   imagesStylet should be shaped with a gentle curve to approximate the trajectory the blade has taken to the airway


Curved “indirect” video systems (standard GlideScope, C-MAC D-blade, McGrath video laryngoscope, Pentax airway scope, King Vision video laryngoscope)


   imagesOpen mouth with a finger/scissor or similar technique


   imagesInsert the device in the midline, staying opposed to the dorsal surface of the tongue


   imagesAdvance and rotate the blade around the tongue, staying in the midline, while watching on the video screen to identify key midline airway landmarks (uvula and tip of epiglottis)


   imagesAdvance until the blade rests in the vallecula


   imagesGently tilt the blade and cranially bring the vocal cords into view on the screen. Do not place the device too close to the glottic inlet as this impedes tube passage.


   imagesIf the device has a channel to hold and launch the ETT, gently push the tube through the channel and past the vocal cords after first ensuring the vocal cords are in the center of the video screen


   imagesIf the device requires the use of a stylet, preference should be made for a rigid preshaped stylet as these do not deform during intubation. Malleable stylets should be shaped with a more aggressive curve to mimic the shape of and trajectory taken by the blade.


   imagesPlace the stylet-loaded tube in the right corner of the mouth with the length of the tube parallel to the ground (3 o’clock position). Advance the tube while rotating the tube in a counterclockwise position until the tube aligns with the curvature of the blade (12 o’clock position). Advance the tube through the vocal cords. If unable to fully pass the tube, withdraw the stylet slightly to allow for more mobility. Withdraw the stylet.


   imagesInflate the cuff (for cuffed tubes)


imagesProof of Intubation


   imagesConfirm tube placement with breath sounds, chest rise, and colorimetric or quantitative end-tidal carbon dioxide


imagesPostintubation Care


   imagesSecure the ETT


   imagesOrder portable chest x-ray


   imagesConnect to a mechanical ventilator, if appropriate


   imagesStrategy for ongoing sedation


COMPLICATIONS



imagesFailed intubation with hypoxic insult


imagesNeed for surgical cricothyrotomy


imagesEsophageal intubation


imagesAirway bleeding and swelling


imagesDamage to vocal cords


imagesDamage to teeth, lips, or tongue


imagesHemodynamic decompensation following RSI medications


SAFETY/QUALITY TIPS




imagesProcedural


   imagesYour eyes should start out looking in the mouth for blade placement, then shift to the screen for optimal blade advancement, then back to the mouth to place the tube near the tip of the blade, then back to the screen to deliver the tube through the cords.


   imagesWhen using video laryngoscopy, do not place the blade too close to the vocal cords as this limits the ability to easily pass the ETT. In practice, this means not trying to get the “best view of the cords” on the screen, rather, keeping a slightly suboptimal view of the cords on the bottom of the screen, which makes tube delivery much easier.


   imagesIf you are having difficulty passing the tube through the vocal cords, withdraw the stylet and advance the tube


   imagesWhen able, use the proprietary stylet and adjunctive equipment. The proprietary stylets are designed to exactly match the curvature of the blade.


imagesCognitive


   imagesStandard geometry video laryngoscopes will provide an excellent view of the glottis in most cases, can function using direct or indirect technique, and offer comparatively easy tube delivery. Hyperangulated geometry blades provide an excellent view of the cords in almost every case, including cases where standard geometry view is inadequate, but can only be used by the indirect/video approach, and tube delivery can be more challenging.


   imagesIf the ETT needs to be adjusted, consider doing so under video guidance


   imagesPractice with the video laryngoscopy system before using it clinically, especially if the device features a hyperangulated geometry blade


   imagesSelect the right device for the right patient. Standard geometry video laryngoscopy allows for direct visualization if secretions or blood obscure the screen. Hyperangulated geometry requires less lifting force and may be easier in patients requiring cervical spine immobilization.

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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Video Laryngoscopy
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